2017 Employee Benefits Guide - Lake Charles Memorial Hospital

Transcription

Everything your healthcare should be!
2017 Employee Benefits Guide
I am pleased to present to you Lake Charles Memorial’s benefit guide for 2017. In this guide
you will find valuable information to assist with selecting the plans that are right for you and
your family’s individual needs. In order to secure your coverage for 2017, you are required
to meet with an enrollment counselor during the period of November 8th -22nd. Throughout
Open Enrollment you have the opportunity to participate in a variety of attractive benefits,
including:
•
•
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•
•
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Medical Insurance
Dental Insurance
Vision Insurance
Basic and Voluntary Term Life Insurance
Long and Short Term Disability
Wellness
•
•
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•
•
Hospital Indemnity
Retirement Planning
Whole Life Insurance
Critical Illness Insurance
Accident Insurance
Flexible Spending Accounts
When you sit with an enrollment counselor again this year they will be enrolling you directly
onto your SmartBen account. We’ve had great success with SmartBen, but if you feel you
need help navigating the site, please take this opportunity to ask your enrollment counselor
for guidance. Throughout the year you can view your account, make life event changes to your benefits, access important
documents and much more!
This will be our fourth year administering the Get Healthy, Stay Healthy Wellness Program. To incentivize engagement in
our wellness program, our wellness committee structured a points system that would reward your active participation. Your
participation has been recorded by WellSteps and those participation points will determine your 2017 medical plan premium
as either a Gold, Silver or Bronze participation level.
This year we have made a very positive change to your medical benefits. Effective 1/1/2017, not only will the deductible
in the Lake Charles Memorial PHO tier cross apply with the Aetna tier deductible, but the coinsurance portion will be equal to
that of the PHO tier as well; 80/20. This means, although you are still required to have written approval
from the Medical Committee to use an Aetna provider, once approved and your deductible is met,
you are responsible for 20% of the cost for using an Aetna provider rather than 40%. In addition, if you
are approved to see a specialist in the Aetna network, there will be a $55 copay and the deductible will not apply. This is the
same in the PHO tier.
Also beginning 2017 we will no longer be utilizing ScriptCare as our Pharmacy Benefits Manager, we are moving to Express
Scripts. With this change we are expanding our step therapy program. Step Therapy is a program designed exclusively for
people who have certain conditions—arthritis, high blood pressure and high cholesterol, for example—that require them to
take medications regularly. Express Scripts’ Step Therapy program is all about value—about getting the most for your money.
Most simply, that means getting a tried-and-true medication that’s proven safe and effective for your condition, and getting it at
the lowest possible cost. Please see pages 7-9 of this guide for more details on the pharmacy benefits as well as the Express
Scripts formulary.
Lake Charles Memorial Health System takes pride in being able to offer comprehensive and affordable benefits to our employees
and values the dedication you all have to the success of our health system. Information about all of the benefits available to you
can be found in this Employee Benefits Guide and on the LCMH Intranet. If you have any questions or concerns, please contact
your Human Resource Representative.
Thank you for being a part of the LCMH family, and we look forward to a successful 2017!
Sincerely,
Larry M. Graham
President
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We are Memorial. Everything your healthcare should be.
2017 employee benefit guide
Important Information As
You Prepare For Your
2017 Benefit Elections
Changing your Benefits During the Year
IRS regulations limit when you can make changes to your
benefits during the year. Once enrolled, you cannot
change your medical, dental or vision coverage, or your
FSA elections outside annual Open Enrollment unless you
have a permitted change under IRS rules. If you have
an eligible change or a question related to an eligible
change, contact Human Resources as soon as possible
as you only have 30 days from the event to make any
changes.
Examples of events that may allow you to make benefit
changes:
• Change in Legal Marital Status
• Change in Number of Dependents
• Change in Dependent Eligibility • Change in Employment Status (including spouse
employment status)
Paying for Benefits with Pre-Tax Dollars
Your share of the cost for medical, dental, vision care and
flexible spending accounts are deducted from your pay
on a pre-tax basis, as allowed by the IRS. This saves you
significant money by reducing your taxable income. Short
term disability, voluntary life insurance and all Unum
product premiums are paid with after-tax dollars. You have
the option of making pre-tax or after-tax contributions to
your 403b Retirement account.
Who is considered an eligible dependent child?
Your legal dependent child is eligible for coverage until
the end of the month in which he or she turns age
twenty-six (26), regardless of marital or student status. If
you have a disabled dependent please speak to our HR
Benefits Department as that dependent may be eligible
beyond age twenty-six (26).
TABLE OF CONTENTS
Important Information/SmartBen........................................ 3
Physicians Hospital Organization (PHO) Network................. 4
Group Health Plan....................................................... 5-6
WellSteps Wellness Program............................................ 6
Prescription Drug Benefits.............................................. 7-8
Step Therapy Program..................................................... 9
Dental........................................................................ 10
Voluntary Vision Insurance ............................................. 11
Flexible Spending Account........................................ 11-12
Employer Paid Basic Life and Accidental Death &
Dismemberment (AD&D) Insurance................................... 13
Voluntary Term Life Insurance.......................................... 13
Voluntary Short Term Disability........................................ 14
Employer Paid Long Term Disability.................................. 14
Life Assistance Program.................................................. 14
Retirement Planning....................................................... 15
Whole Life Insurance .................................................... 16
Accident Insurance....................................................... 16
Group Critical Illness Insurance (GCI)............................... 17
Group Hospital Indemnity Insurance................................. 17
More Valued Benefits Offered Through
Lake Charles Memorial Health System ....................... 18-19
Children’s Health Insurance Program (CHIP) Notice............ 20
Medicare Part D Notice................................................ 22
Women’s Health and Cancer Rights Act (WHCRA) Notice.. 23
Resources................................................................... 24
SmartBen! A one-stop shop for online self-service benefits enrollment and maintenance!
ONLINE 24/7
• View animated interactive storyboards describing your benefit plan choices.
• Access your benefit information when you need it, not just during regular HR office hours. This
gives you HR and benefit information on demand.
• Use assumption calculators to perform “what if” scenarios on your individual benefits and see
how your elections affect your paycheck.
• View innovative decision support calculators through an individualized benefit experience. These
and other tools make it easy for you to understand and enroll in the best benefit package for you
and your family.
Log on today: www.smartben.com
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Lake Charles Memorial’s Physician Hospital Organization (PHO) Network
Lake Charles Memorial Health System continues to be the healthcare leader in Southwest Louisiana; providing quality healthcare
since 1952. As a Lake Charles Memorial employee you have access to significantly discounted healthcare benefits if you use a
PHO network provider. Our medical plan requires that you first seek approval from the Lake Charles Memorial Medical
Committee before accessing an outside provider.
Below are some need-to-know facts about Lake Charles Memorial’s PHO network.
Utilizing Providers Outside of the PHO Network
Services rendered outside the Lake Charles Memorial PHO
Network will require prior approval from the Medical
Committee of Lake Charles Memorial Health System. Coverage
is contingent upon the provider(s) participating in the Aetna
network. If the service is available within the PHO network,
approval WILL NOT be granted to go outside of the network.
The Approval Process:
If you need treatment that cannot be provided inside of the
PHO network, you must first get a referral letter from your doctor
to submit to the Lake Charles Memorial Health System Medical
Committee. That letter needs to provide background
information on your condition, what treatment is needed and to
which provider(s) and facilities you are being referred. Before
submitting your referral to the Medical Committee, you are
responsible for making sure the provider you choose is in the
Aetna PPO network. Claims will be denied if your provider is
not an Aetna provider. Please visit the Aetna provider website
referenced at the bottom right corner of this page to locate
Aetna providers. You can also contact Meritain Health if you
need help finding a provider.
*Please Note: Childrens Hospital of New Orleans still requires
pre-approval for services. However, if approved, claims will
be covered at the in-network PHO level of benefits.
Lab Services
There are five labs within the PHO network:
1. Lake Charles Memorial Hospital Lab
2. Omega Diagnostics, LLC
3. Pathology Associates of Mid LA
4. Delta Pathology Lab
5. The Pathology Lab
Labs performed at any of the above listed labs excluding Lake
Charles Memorial Lab will be applied to your deductible first
then covered at 80%. Labs are covered at 100% if performed
at the Lake Charles Memorial Lab.If your labs are performed
in a physician’s office and have to be sent out to a lab for the
actual testing, the physician must send your lab samples to an
in-network laboratory in order for the tests to be covered. If your
labs are sent to or performed at a lab that is not in the PHO
network and you did not receive prior approval from the
Medical Committee to utilize the out of network lab, your lab
work claims will be denied. It is your responsibility to make
sure your physician sends your labs to an in-network provider.
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Durable Medical Equipment (DME)
There are four DME providers within the PHO network:
1. Carmichaels Cashway Pharmacy
2. First Option
3. Medical Technologies
4. Lake Area Prosthetics
5. In addition, Aetna DME providers are also covered as
PHO!!
Physician prescribed DME purchased from the above four
providers or any Aetna DME provider will be covered at the
PHO level of benefits. If you purchase any DME from a
provider that is not in the Lake Charles Memorial PHO or Aetna
network, the claim will not be covered. Please visit the Aetna
provider website referenced at the bottom right corner of this
page to locate Aetna providers.
Out of PHO Service Area Employees and
Dependents
If you or your dependent live primarily outside of the Lake
Charles Memorial PHO service area, which is a 100 mile
radius from the hospital located at 1701 Oak Park Blvd., Lake
Charles, LA 70601, we understand that your residence may
not be within reach of the PHO network. However there are
Aetna providers available to you. If you register yourself or
your dependent on SmartBen as out of area, your claims for
services rendered by an Aetna provider will be covered at the
PHO level of benefits. Services rendered by a provider that
is not in the Aetna network will not be covered. Please visit
the Aetna provider website referenced below to locate Aetna
providers.
Locating an Aetna Provider
If there is not a Lake Charles Memorial PHO provider that
provides the services you are seeking, you can locate an
Aetna provider in your area by visiting www.aetna.com/
docfind/custom/mymeritain. Please be sure to choose the
“Open Choice PPO” plan in the search options. You can
also contact Meritain Health at 866-760-9569 if you need
help locating an Aetna provider. Please remember, if the
service is available within the PHO network, the services
will not be covered elsewhere.
Group Health Care Plan
Employees who work on a regular full-time or on a regular part-time basis are eligible to participate
in the group health insurance plan. Your health insurance benefits will be effective on the first of the month after your
date of hire or the first of the month after the date in which you become benefits eligible. Please review the following outline of the
comprehensive plan. A full Summary Plan Description is available on SmartBen, the LCMH Intranet and in the Human Resources
Department.
Schedule of Medical Benefits
LCMH Physician Network1
Approved Aetna Providers
DEDUCTIBLE, PER CALENDAR YEAR (Deductibles cross apply)
Per Covered Person
$750
$2,000
Per Family Unit
$2,250
$6,000
NOTE: Charges made by any provider other than a LCMH PHO network provider will not be eligible under this plan unless preapproved in writing by the Lake Charles Memorial
Medical Committee. Coverage through an Approved Aetna Provider as referenced above will still require written pre-approval. Emergency care is an exception.
MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR (Out-Of-Pocket Maximums Cross Apply)
Per Covered Person
$7,150
$7,150
Per Family Unit
$14,300
$14,300
$40 copay, no deductible
80% covered after deductible
Specialist
Preventative Care Services
Services include but are not limited to these services which
should be coded as “Routine”: Exams, Pelvic Exams, Pap
Testing, PSA Testing, Immunizations, Colonoscopy Screening
and Routine Well Child Care
100%
Diagnostic Lab Services
During a Physician Office Visit
Performed at LCMH Lab
Performed at all other approved labs
100% covered, no deductible
100% covered, no deductible
Durable Medical Equipment (DME)
Urgent Care
Moss Memorial Urgent Care
and Memorial Medical Group Urgent Care
Not Covered
$250 copay per visit,
no deductible
$250 copay per visit, no
deductible; R&C charges may
be applied
Office Visits
Primary Care Physician
(Pediatrician, Family Practitioner, Internal Medicine, General
Practitioner, OB/GYN)
Emergency Room
Hospital Services2
Pre-Certification is required for all in-patient medical, surgical and mental health services, skilled nursing facilities, home health care, hospice, private duty nursing, outpatient surgical
procedures excluding surgery rendered in a physician’s office, MRI, PET and CT scans, chemo, radiation, physical, and occupational therapy, initial visit dialysis and transplants,
including transplant second opinions.
In-patient
$500 copay per admission;
no deductible
Ambulatory Surgery
$500 copay per admission;
no deductible
Out-patient: includes, but not limited to X-Ray, Radiation Therapy,
Chemotherapy, Hemodialysis
Physician Services
In-patient
Out-patient
In-network providers are not subject to the Reasonable and Customary charge allowance.
2
Hospital Expense deductible and coinsurance charges,not including copays, will remain eligible under the LCMH Employee Discount Program. The Physician deductible and coinsurance
charges relative to Hospital Inpatient and Outpatient expenses are not subject to the LCMH Employee Discount Program.
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Health Insurance Rates Per Pay Period
COVERAGE LEVEL
FULL-TIME EMPLOYEES
Bronze
Silver
Gold
$52.14
$23.19
$16.48
Employee + Spouse
$274.73
$180.03
$160.48
Employee + Child(ren)
$258.31
$168.31
$149.53
Family
$385.62
$259.22
$234.51
Employee Only
Wellness Points Earned in 2016
499 points or less
COVERAGE LEVEL
500-599 Points
600+ Points
PART-TIME EMPLOYEES
Bronze
Silver
Gold
Employee Only
$102.77
$59.76
$50.66
Employee + Spouse
$323.07
$214.55
$192.75
$306.69
$202.86
$181.82
Family
$458.31
$311.12
$283.02
Wellness Points Earned in 2016
499 points or less
500-599 Points
600+ Points
Please Note: 2017 Medical Premiums are based on points earned participating in the wellness program during 2016. Bronze level also
includes employees that did not participate in the wellness program.
WellSteps Wellness Program
Lake Charles Memorial Health System offers a voluntary comprehensive wellness program for all employees enrolled in the
medical insurance. We are dedicated to supporting you and your family members throughout your journey to improved health
and wellness. By choosing to participate, you can earn a discount on your medical insurance by completing wellness activities. If you choose not to participate in the program or activities by the last Friday of October, you will pay the regular (Bronze Level)
insurance rate for your medical insurance. How it works: Each year, starting in January, a list of wellness activities will be posted on your WellSteps account. Simply log on to your
account at wellsteps.com/lcmh. There are two discount levels, Silver (lower) discount and a Gold (higher) discount. All of the
activities to earn a Silver discount are required. To go above & beyond, earning a Gold Discount, you can choose from a menu
of items listed on your WellSteps account. All wellness rewards activities are due the last Friday of October, no exceptions.
If you are a new hire or have never participated in the wellness program you need to
REGISTER YOUR WELLSTEPS account NOW:
1.
2.
3.
4.
Go to wellsteps.com/lcmh and click “REGISTER”
Enter your username: LMCH + Employee ID number (ex: LCMH12345)
Complete the registration form
Complete the Personal Health Assessment (PHA)
NEW HIRES: If you complete the PHA within 30 days of the effective date of your medical
insurance, you will receive the Silver discount for the remainder of the current year.
Questions? Call the wellness department at 494-2992 or 494-2771 or
view the wellness jumpstart video at www.wellsteps.com/lcmh 6
Using Medical Plaza
for your prescription drug
needs saves you and your
family significantly!! There is
no drug deductible to meet
when you fill prescriptions
at Medical Plaza.
Schedule of Pharmacy Benefits
MEDICAL PLAZA PHARMACY ALL OTHER EXPRESS SCRIPTS PHARMACIES
($250 Individual &
(No deductible to meet)
$500 Family deductibles apply)
$15 co-pay
$37.50 co-pay
$37.50 co-pay
Not available
Preferred Brand (30 day supply)
Preferred Brand (90 day supply)
$60 co-pay
$150 co-pay
$150 co-pay
Not available
Non Preferred Brand (30 day supply)
Non Preferred Brand (90 day supply)
$100 co-pay
$250 co-pay
$250 co-pay
Not available
Generic (30 day supply)
Generic (90 day supply)
Specialty Drugs
MEDICAL PLAZA PHARMACY
*ACCREDO SPECIALTY PHARMACY
30 day supply
Greater of $200 or 20%,
$500 max per script
Greater of $200 or 20%;
$500 max per script
90 day supply
$1,000 max per script
$1,000 max per script
*Specialty medications must be ordered from Medical Plaza pharmacy or Accredo. Specialty medications require prior authorization. Your
physician can call 1-800-803-2523 to obtain authorization. Quantity limits may apply.
New Diabetic Program through Managed Care Concepts (MCC)!
Beginning January 1st 2017, we will have a new diabetic program through MCC which will coordinate with our Medical Plan!
Below are some of the benefits for our diabetic members…
-
There is no cost what-so-ever for strips, monitors or meters
Testing strips are delivered to your home
You will receive a minimum of two vials per month based on usage
If the meter is defective it will be replaced at no charge
Test results are automatically uploaded to an MCC diabetic nurse database
You will be contacted by the MCC nurse on a regular basis for management of your condition
Please call 866-750-2723 and ask for the Healthy Track Nurse.
Medical Plaza…at your service!
Did you know Medical Plaza Pharmacy is open from 8 a.m. to 5 p.m. Monday – Friday? Courier service is available to all
employees of Lake Charles Memorial Health System. Whether you are located at Moss Memorial, The Women’s Campus
or Nelson Road, if you call by noon your prescription could be delivered by 5 p.m.!! Please don’t miss out on this
convenient benefit!
Not only is Medical Plaza convenient, but also saves you money by avoiding the $250 individual
deductible and $500 family deductible which applies if you purchase prescriptions anywhere else.
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Medications and immunizations recommended by the U.S. Preventive Services Task Force and mandated under PPACA will be covered at 100% in
their most cost-effective form when purchased at Medical Plaza. This includes Women’s Preventive Care Drugs such as generic contraceptives.
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Dispense As Written (DAW) Process
The Dispense as Written DAW process facilitates the utilization of the most cost effective prescription type, Brand Name Vs. Generic
Drug, while adhering to physician written orders for the needs of the patient. Please consult with your physicians concerning what
form of prescription is appropriate for your individual needs.
What is Prior Authorization?
Prior Authorization is a program designed to ensure that certain prescription drugs are covered under your benefit plan for
specific medical purposes. This helps keep prescription-drug costs in line, while also providing the medications you need.
How Does Prior Authorization Work?
Your plan covers a list of medications, based on the advice of independent doctors, pharmacists and other licensed professionals.
They review the latest research on prescription drugs, and recommend cost-effective medications that have been tested and
approved by the U.S. Food and Drug Administration (FDA) to be safe and effective. At some time, you may be prescribed a
medication that falls outside of this recommended group. When this occurs, your prescription may be “flagged” at the pharmacy,
and your pharmacist will get a computerized message saying your prescription needs “prior authorization.” This simply means
that more information is needed to determine whether your plan will cover the prescription drug. In the next step, your doctor (or
sometimes the pharmacist) will call the Express Scripts Prior Authorization phone line—open 24 hours a day, every day. During the
call, an Express Scripts representative will check your benefit plan guidelines to determine whether the medication is covered.
Compound Drugs
Compound medications will require a prior authorization. Please contact RxBenefits at 1-800-334-8134 for details.
Important News for ADD/ADHD Medications
Lake Charles Memorial Health System requires Letters of Medical Necessity for Stimulant Medications such as but not limited to
Adderall, Focalin and Vyvanse. If you or any of your covered dependents use these medications your provider will be asked
annually to complete a letter of medical necessity and send that to your pharmacy before your prescription can be filled.
Communication will be between the pharmacy and the provider’s office. Acid Reflux Medications (PPIs)
Lake Charles Memorial Health System covers physician prescribed over-the-counter (OTC) PPIs at your standard Generic copay.
Examples include: Nexium OTC®, Prilosec OTC®, Prevacid® 24HR and the store brand/off label over-the-counter omeprazole
equivalents. These prescriptions are covered with just your standard Generic copayment! Lake Charles Memorial does not cover
Brand PPI medications to: Aciphex, Prevacid, Prilosec, Protonix, Nexium, and Dexilant.
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Step Therapy Program
The Lake Charles Memorial plan includes a step therapy program that promotes the use of generic medications first. If you
choose to use certain brand-name drugs before trying a generic medication, your prescription may not be covered and you
may need to pay the full cost.
What is Step Therapy?
In Step Therapy, medications are grouped in categories, based on cost:
•Front-line medications — the first step — are generic medications proven safe, effective and affordable. These medications should be tried first because they can provide the same health benefit as more expensive medications, at a lower cost.
•Back-up medications — Step 2 and Step 3 medications — are brand-name medications such as those you see advertised on TV. There are lower-cost brand medications (Step 2) and higher-cost brand medications (Step 3). Back-up medications always cost more than front-line medications.
CHOOSING WISELY
HOW IT WORKS
How it Works
The world of prescription medications can be confusing. We’re constantly bombarded
The next time your doctor writes you a prescription:
with television ads promoting the benefits of brand-name
And, for
some doctor writes you a prescription:
Themedications.
next time
your
• Ask your doctor if a generic medication — listed by your plan as a front-line
there are dozens
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—How
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what’s best?
• If you’ve already tried a front-line medication, or your doctor decides one of these
Step Therapy
can help you
sort itaout.front-line medication, or your doctor decides one of these medications isn’t appropriate for you,
•If you’ve
already
tried
medications isn’t appropriate for you, then your doctor can prescribe a back-up
then your doctor can prescribe a back-up medication. Ask your doctor
one
of the
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if onelower-cost
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WHAT IS STEP THERAPY?
listed
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by your plan is appropriate.
In Step Therapy, medications are grouped in categories, based on cost:
• You can get a higher-cost brand-name medication at a higher copayment if the front-line
•You• can
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a higher-cost
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at a higher copayment
if medications
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proven safe,
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aren’t
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you. These medications should be tried first because they can
effective
affordable.
provide the same health benefit as more expensive medications, at a lower cost.
IT JUST MAKES SENSE
Why Generic Medications?
It makes good sense to ask for front-line medications first because, for most everyone,
• Back-up medications — Step 2 and Step 3 medications — are brand-name
they work as well asthat
brand-name
— and
almost always
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The only real difference is cost. Generics may
cost DESIGNED
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brand-name
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BY DOCTORS AND PHARMACISTS
WHY GENERIC MEDICATIONS?
Step Therapy is a program developed under the guidance of independent doctors,
pharmacists and other medical experts. Together with Express Scripts, these medical
professionals review the most current research on thousands of prescription medications.
Then they carefully choose the appropriate medications as front-line medications.
How
The Step
Therapy
Process
Works
MD
You have difficulty sleeping
and your doctor gives
you a prescription for Lunesta.
Lunesta is not
a front-line
medication
You take the prescription
to your pharmacy and find out
that Lunesta is a back-up drug.
Generic medications are less-expensive versions of brand-name medications that have
been on the market for a number of years. Although generics usually have a different
name, color and/or shape, they have exactly the same chemical makeup and the same
effect in the body as their original brand-name counterparts. The only real difference is
cost. Generics may cost less than their equivalent brand-name medications.
MD
The first and simplest choice is for
your pharmacist to call your doctor’s office
and ask if it’s OK to substitute a generic
front-line medication, such as zolpidem.
Most people will do well on the front-line medication.
But if for some reason that’s not the case and your
doctor decides it’s time to move to a back-up medication,
you can do that, but you’ll pay a higher copayment.
Note: If your doctor can’t be reached right away, your pharmacist may dispense enough
medication — at full cost — until your doctor’s office can be contacted.
Step therapy applies to the following drug classes: COX-2, Hypnotics, Nasal Steroid, NSAID, Ophthalmic Antiallergy, PPI,
Tetracyclines-Oral, Topical Acne, Topical Antifungal, Topical Corticsteriods, Topical Immunomodulators, ARB, Avodart, Bisphosphonates, Fenofibrate, HMG, Inhaled Corticosteroids, Metformin, Methotrexate, Overactive Bladder, SGLT2 Inhibitors, SFLT2/
DDP-4 Combo, Thiazolidinedione.
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Dental Insurance
To aide in proper oral hygiene, the Lake Charles Memorial Health System Dental Plan allows for bi-annual exams, cleaning, and
x-rays, performed by any dentist of your choice, covered at 100%. There is no network of providers to adhere to. Your dental
benefit election is separate from your medical plan election, therefore, you may elect coverage based on your needs and that of
your family. All regular full-time and regular part-time employees are eligible to participate in the plan.
Your dental insurance benefits will be effective on the first of the month after your date of hire or the first of the month after the
date in which you become benefits eligible.
PLAN FEATURES
$50 per individual
$150 per family
Calendar Year Deductible
Calendar Year Maximum (Per Individual)
Orthodontic Lifetime Maximum (Per Individual)
DENTAL BENEFITS
Preventive and Diagnostic
• Routine Examinations and Cleanings (once every six months)
• Fluoride for Children (under age 19, once every six months)
• Space Maintainers (under age 19, once every five months)
• X-Rays (Full mouth, limited to children under age 19, once every five years)
• Bitewings (once every six months)
Restorative Services
• Extractions
• Periodontic Treatment
• Oral Surgery
• Endodontic Treatment
• Fillings
• Crown Repair
• General Anesthesia
• Denture Repair
• Antibiotic Drugs, which are injected by a Dentist or Physician
Major Services
• Crowns
• Restorative—Inlays, Crowns
• Prosthodontics—Removable Dentures, Partials
Orthodontic Expenses
(available to dependent children and adults)
Pay Period Rates
COVERAGE LEVEL
Employee Only
Employee + Spouse
Family Coverage
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FULL-TIME & PART-TIME
EMPLOYEES
$7.91
$15.11
$17.28
$25.22
$1,500
$1,500
AMOUNT COVERED
UNDER PLAN
100%, deductible waived
80%
50%
50%
50%, deductible waived
Voluntary Vision Insurance
Lake Charles Memorial Health System provides vision insurance through Vision Service Professionals (VSP). The comprehensive
benefits package is designed to promote overall good eye health. All regular full-time and regular part-time
employees are invited to participate in the plan. Your vision insurance benefits will be effective on the first of the
month after your date of hire or the first of the month after the date in which you become benefits eligible. Remember, VSP
does not issue cards. If elected, you will identify yourself at a provider’s office as a VSP member and
the provider will verify coverage by your social security number. VSP customer service number 1-800-877-7195
SERVICE
NETWORK
OUT-OF-NETWORK ALLOWANCES
Exam (1 per 12 months):
$10 co-pay
Up to $45
Materials (1 per 12 months):
$25 co-pay
Allowance as described below
Standard Plastic Lenses
(1 per 12 months):
Single Vision
Bifocal
Trifocal
Lenticular
Progressive
Covered
Covered
Covered
Covered
$55 - $175 copay
Up
Up
Up
Up
Up
(copay depends on type of progressive lens)
Frames (1 per 24 months, 1 per
12 months for children age 18 and
under):
Member may select any frame
available
Contact Lenses (1 per 12 months):
Fit, follow-up and materials
In lieu of eyeglasses and lenses
• Elective
• Medically Necessary
$150 allowance;
20% discount off the overage
to
to
to
to
to
$30
$50
$65
$100
$50
Up to $70 retail allowance
$150 allowance;
15% discount off the contact lens exam
Covered in full
Up to $105 allowance
Up to $210 allowance
PER PAY PERIOD RATES
Employee Only
$2.73
Employee and Child(ren)
$5.89
Employee and Spouse
$5.49
Family
$9.39
A directory of vision care providers may be located online: www.vsp.com.
Flexible Spending Account
Whether you are married with children, single with no children, a single parent or any other lifestyle status, a Flexible Spending
Account (FSA) can save you money. An FSA allows you to set aside pre-tax dollars to cover qualified expenses that you would
normally pay out of your pocket with after-tax dollars. You pay no federal income or state income taxes on the money you place in
your FSA. The FSA is actually comprised of two accounts: a health care spending account and a dependent care account.
Employees who work on a regular full-time basis or on a regular part-time basis are eligible to participate. Your FSA contributions
will not roll over into the next year. You must re-enroll in the FSA program each year.
With new system changes, you can:
• Access plan information on-the-go with the new Meritain Health Flex/CDHP app.
• Avoid the fax machine or paperwork through online claims submission.
• Stay up-to-date with real-time online account information, such as claims and payment status.
• Save a stamp with the ability to reimburse account overpayments online.
• And more! To better route your inquiries to our specialists, the Flex/CDHP Customer Service number
has changed to 1.800.566.9305.
11
Flexible Spending Account continued
Health Care Spending Account
The Health Care Spending Account may be used for any medical, prescription drugs, dental or vision care expenses not
reimbursed by Lake Charles Memorial Health System’s health plan. These expenses may include the deductible, coinsurance, or costs
not covered by the plan. The maximum yearly contribution is $2,550.
With your Health Care Spending Account you will receive a benefits debit card, “Benny Card”. This card works like any Visa
or Mastercard but can only be used to pay for eligible expenses such as prescription drugs, medical copays, as well as vision
and dental expenses. For a complete list of eligible expenses, visit www.mymeritain.com. Lost or stolen cards will require a $5
replacement fee. Cards are issued once when you initially enroll; they are not reissued annually.
Dependent Care Account
The Dependent Care Account may be used to pay for dependent care expenses that enable you or your spouse to work. You may
claim dependent care expenses for your children under age 13, or for a dependent adult or child over 13 who requires day care.
Expenses that qualify for the Dependent Care Account include the cost of care in licensed day care centers, pre-school tuition and
care provided in or outside of your home, such as an adult day care facility. The maximum yearly contribution is $5,000.
End Of The Year Run-Out
Healthcare FSA: Lake Charles Memorial has opted for the grace period extension offered by the IRS, which allows an additional
2 1/2 months (3/15/17) to incur expenses toward your healthcare FSA after the plan year has ended. These expenses incurred
between January 1st and March 15th cannot be paid for using your Benefit Debit Card (Benny Card). Charges to your Benny Card
are credited to current year contributions. Expenses incurred in the grace period must be submitted by paper claim for reimbursement.
Claim forms can be found on the LCMH Intranet and on SmartBen.
Healthcare and dependent care FSA claims can be submitted online at www.meritain.com or manually submitted using an FSA
claim form with proper documentation until 4/15/2017. Your Benny card should only be used for current year
expenses!! If used during 2017 to pay 2016 expenses, the purchase will be out of compliance and a
hold will be placed on your card until reconciled. You can find the FSA claim form on SmartBen.
Be sure to save your receipts!
Some expenses will require additional information, including receipts to verify eligibility of the expense to comply with IRS rules.
That is why it is important to save all receipts for expenses which you use your Benny Card to pay. If you fail to submit
receipts promptly when they are requested, the expenses will be declared ineligible and you will have
to reimburse your account. If there is continued non-compliance, you could jeopardize the tax-exempt
status of your account and lose access to your benefit debit card.
Important information about your FSA account is delivered to you via US mail. Do not ignore mail you
receive from Meritain Health!
*TIP: If you are asked to provide a receipt from a physician or dentist’s office and can’t find the receipt, contact their office and
ask if they can provide you with an additional copy. Don’t pass up the opportunity to use your pre-tax dollars!
WITHOUT THE FSA
Employee Gross Salary
WITH THE FSA
$30,000 Employee Gross Salary
FSA Contribution
$0 FSA Contribution
Taxable Wages
$30,000 Taxable Wages
Estimated federal, state & social security taxes
Out-of-Pocket Medical / Daycare Expenses
$9,195 Estimated federal, state & social security taxes
- $2,000 Out-of-Pocket Medical / Daycare Expenses
Employee's Take Home Pay
$18,805 Employee's Take Home Pay
Employee Annual Savings
$30,000
$2,000
$28,000
- $8,582
$0
$19,418
$613
You can monitor your flex accounts online by going to www.meritain.com and creating an account. There you can view your account
balances, see activity details and more...
12
2017
employer Paid basic life and accidental Death and Dismemberment (aD&D)
employer
PaidHealth
basic
life
anda accidental
Death
Dismemberment
Lake
Charles Memorial
System
provides
Basic Life and AD&D
benefitand
through
Cigna at no cost to full(aD&D)
time active
LakeCharlesMemorialHealthSystemprovidesatnocosttofulltimeactiveemployees,aBasicLifeandAD&Dbenefitthrough
employees.
The amount of the AD&D insurance benefit is equal to the amount of your life insurance benefit. This benefit will be
Cigna.TheamountoftheAD&Dinsurancebenefitisequaltotheamountofyourlifeinsurancebenefit.Thisbenefitwillbeeffective
LakeCharlesMemorialHealthSystemprovidesatnocosttofulltimeactiveemployees,aBasicLifeandAD&Dbenefitthrough
effective
onday
the of
firstthe
day
of the
month following
days of employment.
on the first
month
following
90 days 90
of employment.
Cigna.TheamountoftheAD&Dinsurancebenefitisequaltotheamountofyourlifeinsurancebenefit.Thisbenefitwillbeeffective
on the first day of the month following 90 days of employment.
1.5×YourAnnualSalary
employer Paid life and aD&D benefit
1.5×YourAnnualSalary
employer Paid life and aD&D benefit
$500,000
Maximum benefit
$500,000
Maximum benefit
Voluntary Term life Insurance
Voluntary Term life Insurance
Guaranteed Issue
(not greater than
Guaranteed
Issue
5x annual earnings)
(not greater than
5x annual earnings)
Max benefit
(not greater than
Max benefit
5x annual earnings)
neW
enRollee
neW
enRollee
$500,000
$500,000
eMPloYee
eMPloYee
CURRenTlY
CURRenTlY
enRolleD
enRolleD
Up
to an additional
Up
$20,000
to an additional
(not to exceed the
$20,000
GI amount)
(not to exceed the
GI amount)
laTe
enRollee
laTe
enRollee
neW
enRollee
neW
enRollee
$20,000
$20,000
$25,000
$25,000
sPoUse
sPoUse
CURRenTlY
CURRenTlY
enRolleD
enRolleD
laTe
enRollee
laTe
enRollee
$0
$0
$0
$0
$100,000
$100,000
$100,000
$500,000
$500,000 $500,000 (Not
to exceed 50% of
(Not to exceed 50% of
$100,000
$100,000
$100,000
the employee benefit)
the
employee benefit)
$500,000
$500,000 $500,000 (Not
to exceed 50% of
(not greater than
5x annual earnings)
$10,000
$10,000
$10,000
$5,000
$5,000
$5,000
Purchase Increments
$10,000
$10,000
$10,000
$5,000
$5,000
$5,000
Purchase Increments
In addition
to your employer
lifeand
insurance,
you have
opportunity
to purchase
life insurancetoprotection
All
active, eligible,
regularpaid
full term
time
regular
partthe
time
employees
have term
the opportunity
purchase on
term life
a
basis
you
arethrough
a newlyCigna.
eligible
orare
part
employee,
youor
may
elect
coverage
in $10,000
In voluntary
additionprotection
to
yourthrough
employer
paidIfterm
life
insurance,
you have
opportunity
to purchase
term
life
insurance
protection
on elect
insurance
on a Cigna.
voluntary
basis
If full
youthe
a time
newly
eligible
full
part
time
employee,
you may
incrementsuptofive(5)timesyourannualearningsupto$500,000withoutprovidingamedicalevidenceofinsurabilityform.If
a voluntary
basis through
Cigna. up
If you
are(5)
a times
newlyyour
eligible
full earnings
or part time
employee,
youwithout
may elect
coverage
in $10,000
coverage
in $10,000
increments
to five
annual
up to
$500,000
providing
a medical
evidence of
youarecurrentlyenrolledintheVoluntaryLifeprogram,youmayeithercontinuewithyourcurrentbenefitamountorincreaseyour
incrementsuptofive(5)timesyourannualearningsupto$500,000withoutprovidingamedicalevidenceofinsurabilityform.If
insurability
form. If you are currently enrolled in the Voluntary Life program, you may either continue with your current benefit amount or
currentbenefitamountinaccordancewiththetableshownabove.AmountselectedovertheGuaranteedIssueamountrequires
youarecurrentlyenrolledintheVoluntaryLifeprogram,youmayeithercontinuewithyourcurrentbenefitamountorincreaseyour
increase
your current benefit amount in accordance with the table shown above. Amounts elected over the Guaranteed Issue amount
completion
of a medical
evidence
of insurability
form and
must
bemust
approved
by the insurance
carrier. carrier.
currentbenefitamountinaccordancewiththetableshownabove.AmountselectedovertheGuaranteedIssueamountrequires
requires
completion
of a medical
evidence
of insurability
form
and
be approved
by the insurance
completion of a medical evidence of insurability form and must be approved by the insurance carrier.
IfIfyouareenrolledinthevoluntarylifeprogram,youhavetheopportunitytopurchaselifeinsuranceforyourspouseandchild(ren).
you are enrolled in the voluntary life program, you have the opportunity to purchase life insurance for your spouse and child(ren).
Youcanenrollyourspousein$5,000incrementsuptoamaximumof$100,000,however,thespouseamountcannotexceed
Ifyouareenrolledinthevoluntarylifeprogram,youhavetheopportunitytopurchaselifeinsuranceforyourspouseandchild(ren).
You
can enroll your spouse in $5,000 increments up to a maximum of $100,000, however, the spouse amount cannot exceed
50%
yourbenefit
benefitamount.
amount.The
Therate
ratefor
forspouse
spousecoverage
coverageisisbased
basedon
onthe
theemployee’s
employee’sage.
age. IfIf not
not newly
newly eligible,
eligible, spouse
spouse coverage
coverage
Youcanenrollyourspousein$5,000incrementsuptoamaximumof$100,000,however,thespouseamountcannotexceed
50%
ofofyour
requires
a
medical
evidence
of
insurability
form
and
must
be
approved
by
the
insurance
company.
50%
of
your
benefit
amount.
The
rate
for
spouse
coverage
is
based
on
the
employee’s
age.
If
not
newly
eligible,
spouse
coverage
requires a medical evidence of insurability form and must be approved by the insurance company.
requires a medical evidence of insurability form and must be approved by the insurance company.
You may also elect to cover your unmarried dependent children age 26 or younger. Child coverage can be purchased at $2,000
You
may alsoChildren
elect to cover
unmarried
dependent
children
26 or younger.
coverageyou
canelect
be purchased
or $5,000.
notyour
require
medical
underwriting.
The age
monthly
applies Child
to
all children
cover. atat $2,000
You
may also elect to do
cover
your
unmarried
dependent
children
age 26rate
or younger.
Child
coverage can
be to
purchased
$2,000
or $5,000. Children do not require medical underwriting. The monthly rate applies to all children you elect to cover.
or $5,000. Children do not require medical underwriting. The monthly rate applies to all children you elect to cover.
VoluntaryTermLifeinsuranceiseffectiveonthefirstdayofthemonthfollowing90daysofemployment.
Voluntary
Term Life insurance is effective on the first day of the month following 90 days of employment.
VoluntaryTermLifeinsuranceiseffectiveonthefirstdayofthemonthfollowing90daysofemployment.
MonTHlY eMPloYee anD sPoUse RaTes
on employee’s
age)
MonTHlY(based
eMPloYee
anD sPoUse
RaTes
(based on employee’s age)
To DeTeRMIne YoUR MonTHlY PReMIUM:
To DeTeRMIne YoUR MonTHlY PReMIUM:
AmountofInsuranceXRate=MonthlyPremium
AmountofInsuranceXRate=MonthlyPremium
$1,000
$1,000
eXaMPle:
Employee,Age35,Purchasinga$50,000LifeBenefit
eXaMPle:
Employee,Age35,Purchasinga$50,000LifeBenefit
$50,000X$0.125=$6.25 per month
$50,000X$0.125=$6.25
per month
$1,000
$1,000
age
age25
Under
Under
25
25 – 29
25
30 –– 29
34
30
35
35
40
––
––
34
39
39
44
50
55
55
60
––
––
54
59
59
64
40
45
45
50
––
––
44
49
49
54
Rate/$1,000 of benefit
Rate/$1,000
$0.09of benefit
$0.09
$0.065
$0.065
$0.10
$0.10
$0.125
$0.125
$0.225
$0.225
$0.33
$0.33
$0.57
$0.57
$0.93
$0.93
$1.22
60
$1.22
65 –– 64
69
$2.17
65 – 69Monthly Child Rates
$2.17
Monthly
Child
Rates
$2,000Benefit
$0.18
$2,000Benefit
$0.18
$5,000Benefit
$0.44
$5,000Benefit
$0.44
13
13
Voluntary Short Term Disability
Short Term Disability Insurance from Cigna can replace a portion of your weekly income if you get sick or injured off-the-job and
are unable to work. It is designed to provide a specified weekly benefit income paid to the employee to be used as needed.
Voluntary Short Term Disability coverage is available to all newly eligible regular full-time and regular
part-time employees. A 3/12 pre-existing condition limitation will apply.1
Active full time and part time employees that are not currently enrolled in the Short Term Disability plan may elect coverage during
open enrollment as a late entrant without medical underwriting, however, a pre-existing condition limitation of 12/12 will apply.2
WEEKLY BENEFIT
Maximum Weekly Benefit
60% OF WEEKLY
EARNINGS
TO DETERMINE YOUR MONTHLY PREMIUM:
$1,250
Weekly Earnings × 60% = Weekly Benefit
Weekly Benefit × Rate = Monthly Premium
30 Days for Injury
30 Days for Sickness
Elimination Period
9 Weeks
EXAMPLE:
$800 Weekly Earnings × 60% = $480 Weekly Benefit
$0.425/ $10 of benefit
$480 × $0.425 = $20.40 per month
Maximum Benefit Period
Premium Calculations
$10
Please refer to the Leave of Absence Policy, which can be found on the
LCMH intranet, for your rights under FMLA.
$10
Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including
diagnostic measures,) or for which a reasonable person would have consulted a physician during the 3 months prior to the most recent effective date of insurance.
Such conditions are “pre-existing” and will not be eligible for coverage until you have been insured under this plan for 12 consecutive months after your most recent
effective date of insurance.
1
Late entrants will deviate from footnote #1 above in that the look-back period will be 12 months prior to the most recent effective date rather than 3. The limitation
will remain in force for the 12 months after the most recent effective date of insurance.
2
Employer Paid Long Term Disability
Lake Charles Memorial Health System provides all full-time active employees with Long Term Disability Insurance through
Cigna. Disability Insurance provides the security of knowing your paycheck will not stop if you have an extended disability due to
illness or accident. Upon approval of a disability claim, you will receive 50% of your monthly salary to a maximum monthly benefit
of $6,000 once you have been out of work for 90 days. If your disability is permanent, this benefit may continue until you reach
retirement age.
MONTHLY BENEFIT
50% OF MONTHLY EARNINGS
$6,000
90 Days
Maximum Monthly Benefit
Elimination Period
Life Assistance Program
Cigna provides a Life Assistance Program to help you and your family find a solution and
restore your peace of mind. Some of the services that are available to you and your family:
•
•
•
•
•
Basic clinical and work/life support by phone or web
Up to 3 face to face sessions with licensed behavioral clinicians.*
24/7 phone consultation with CIGNA licensed clinicians
Unlimited access to online research and other key resources
Life events research and qualified referrals (i.e., child care providers)
24/7 support
800.538.3543
www.cignabehavioral.com/cgi
*The LAP is a value added service provided by Cigna and is not related to any benefits of the LCMH Group Medical plan. If you
foresee needing more than the 3 free visits, you need to make sure that the provider you are seeing is in the PHO network as any
claims submitted to Meritain are subject to the terms of the medical plan. Below is a listing of providers in the PHO network that are
also in the CIGNA LAP network. You must first get the referral paperwork from CIGNA before making your appointment.
14
Institute for Neuropsychiatry
Psychiatric Center, LLC
2829 4th Avenue, Suite 150
Lloyd Kelly, LCSW
Molly Larson, LPC
Jeanne’ Wolf, M.A.
324 W. Hale St.
Michelle Godeaux, LPC, LMFT
Suzanne Creel, LCSW
Retirement Planning
403(b) Tax-Deferred Contribution Account
All employees are eligible to participate in the LCMH 403(b) Tax-Deferred Contribution Account upon date of hire. Lake
Charles Memorial Health System has made a conscientious decision to assist employees in saving for their future by enforcing an
automatic enrollment in the 403(b) retirement plan at a 3% contribution level. What this means is that if a new employee does
not personally enroll or decline participation, he or she will be automatically enrolled in the plan and automatically have 3% of
his or her compensation for hours paid deferred into their individual account. Employees are immediately 100% vested in these
contributions. Newly eligible employees will have 90 days to opt out of participation in the plan and request reimbursement of
their contributions.
Since inception, our enrollment in the retirement plan has increased significantly which is our goal. We feel that as an employer,
we have a responsibility to ensure that our employees take advantage of the benefits provided. If you were automatically enrolled
and did not touch your plan by allocating funds or increasing/decreasing your contribution level, you will see an automatic
increase of 1% to your contribution. Meaning, if you were automatically enrolled in 2016 at 3% and made zero changes to your
account, your contribution in 2017 will be 4%.
401(a) Account
Employees who participate in the LCMH 403(b) Tax-Deferred Contribution Account may participate in the LCMH 401(a)
Retirement Planning Account beginning January 1 or July 1, coinciding with or immediately following the date on which all
eligibility requirements are met:
1. Completion of one (1) year of eligibility service, to include 1,000 working hours by the anniversary of your hire date.
2. Attain age 21.
3. Employed in a job classification covered by the Plan as an “eligible class.” You are in an “eligible class” if you are
employed by LCMH in any capacity, and you are not a leased employee.
As a Defined Contribution Plan, LCMH will make a matching contribution to your 401(a) Account equal to 100% of the first 3% of
your contribution to the 403(b) Tax-Deferred Contribution Plan, based on your hours worked and subject to the Federal Matching
Contribution limits. The graded vesting schedule, as illustrated below, applies to the 401(a) Account:
YEARS OF VESTING SERVICE
Less than 2
2, but less than 3
3, but less than 4
4, but less than 5
5, but less than 6
6 or more
VESTED INTEREST
0%
20%
40%
60%
80%
100%
www.lcmhretirementplan.com
Group Number - G62261
Please contact Human Resources or refer to the LCMH Retirement Summary Plan Description for further details. This can be located
on SmartBen, the intranet as well as the retirement website.
Plan Ahead for Your Retirement
How much income do you think you'll need during retirement? According to financial planners, you'll probably need about 70%
to 80% of your pre-retirement income after you retire. Have you thought about where that income will come from? Reaching your
retirement goal is easier with pre-tax contributions from both you and your employer into a retirement plan. The bottom line is, the
more you put away monthly, and/or the higher the rate of return on your investments, the more likely you'll reach your retirement
goal.
Need Advice?
For help with retirement planning needs such as funds allocation, projecting your retirement income requirements, etc., you can
contact Investment Advisor, Jeff Wylie at 985-892-6213 to schedule an appointment.
15
Unum’s whole life insurance is designed to pay a death benefit to your beneficiaries but it can also build cash value you can use
while you are living. The policy accumulates cash value at a guaranteed rate of 4.5%.* Once your cash value builds to a certain
level, you can borrow from the cash value or use it to buy a smaller “paid-up” policy with no more premiums due. If you are
diagnosed with a medical condition that limits life expectancy to 12 months or less, you can request up to 100% of the benefit
amount, to a maximum of $150,000. Your spouse and dependents have this option as well.
*The policy accumulates cash value based on a non-forfeiture interest rate of 4.5% and the 2001 CSO mortality table. The cash
value is guaranteed and will be equal to the values shown in the policy.
Employees must be a U.S. citizen or legally authorized to work in the U.S. to receive overage. Spouses and dependents must live
in the U.S. to receive coverage.
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions
may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For
complete details of coverage and availability, please refer to policy form L-21848 or contact your Unum representative.
Underwritten by: Provident Life and Accident Insurance Company, Chattanooga, Tennessee
Unum complies with state civil union and domestic partner laws when applicable.
unum.com
©2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring
subsidiaries.
Group Accident Insurance
Unum’s accident insurance can pay benefits based on the injury you receive
and the treatment you need, including emergency-room care and related
surgery. The benefit can help offset the out-of-pocket expenses that medical
insurance does not pay, including deductibles and co-pays. Family coverage is
available.
Employees must be a U.S. citizen or legally authorized to work in the U.S. to
receive overage. Spouses and dependents must live in the U.S. to receive
coverage.
This information is not intended to be a complete description of the insurance
coverage available. The policy or its provisions may vary or be unavailable
in some states. The policy has exclusions and limitations which may affect any
benefits payable. For complete details of coverage and availability, please refer
to policy form GA-1 or contact your Unum representative.
See schedule of benefits for a full list of covered injury and treatments.
THIS IS A LIMITED POLICY
Underwritten by: Unum Life Insurance Company of America, Portland, Maine
Unum complies with state civil union and domestic partner laws when
applicable.
unum.com
©2015 Unum Group. All rights reserved. Unum is a registered trademark and
marketing brand of Unum Group and its insuring subsidiaries.
16
A $50 Wellness Benefit
is included in the
Accident policy! See
SmartBen for details
A $50 Wellness Benefit
is included in the
Critical Illness policy!
See SmartBen for details
Group Critical Illness
Unum’s group critical illness insurance can help protect your finances from the expense of a serious health problem, such as a
stroke or heart attack. Cancer coverage is also available. You choose a lump-sum benefit up to $50,000 that’s paid directly to
you at the first diagnosis of a covered condition. You can use the benefit any way you choose. You can use this coverage more
than once. If you receive a full benefit payout for a covered illness, your coverage can be continued for the remaining covered
conditions. The diagnosis of a new covered illness must occur at least 90 days after the most recent diagnosis. Each condition is
payable once per lifetime.
Employees must be a U.S. citizen or legally authorized to work in the U.S. to receive overage. Spouses and dependents must live
in the U.S. to receive coverage.
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions
may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For
complete details of coverage and availability, please refer to policy form CI-1, or contact your Unum representative.
unum.com
©2015 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring
subsidiaries.
Group Hospital Indemnity Insurance
Unum’s group hospital indemnity insurance can complement your health insurance
to help you pay for the costs associated with a hospital stay. It can also provide
funds for the out-of-pocket expenses your medical plan may not cover, such as
co-insurance, co-pays and deductibles. You may also purchase coverage for your
spouse and dependent children. A wellness option can pay an annual benefit for
preventive care.
Employees must be a U.S. citizen or legally authorized to work in the U.S. to
receive overage. Spouses and dependents must live in the U.S. to receive
coverage.
This information is not intended to be a complete description of the insurance
coverage available. The policy or its provisions may vary or be unavailable in
some states. The policy has exclusions and limitations which may affect any benefits
payable. For complete details of coverage and availability, please refer to Policy
form GHI-1, or contact your Unum representative.
This coverage is a supplement to health insurance. It is not a substitute for
comprehensive health insurance and does not qualify as minimum essential health
coverage.
unum.com
©2015 Unum Group. All rights reserved. Unum is a registered trademark and
marketing brand of Unum Group and its insuring subsidiaries.
CU-9786
17
More Valued Benefits Offered Through Lake Charles Memorial Health System
Tuition Reimbursement
Lake Charles Memorial Health System provides eligible employees with the opportunity to participate in courses of study through
accredited colleges or universities and be reimbursed in accordance with policy. Tuition reimbursement is available to regular full
time and part time employees after successful completion of the ninety (90) day introductory period. Courses must be directly job
related or hospital career goal directed and the application must be submitted in advance of the start of any course(s).
Child Care Assistance
It is important to know that your child is well cared for while you are at work. One of the most important decisions you will ever
make as a parent or guardian is choosing quality, affordable child care. Lake Charles Memorial Health System understands this
and provides an assistance program to full-time and part-time employees. The program pays a subsidy for one child per employee
ages 6 weeks to 5 years or until they enter a Pre-K program. Lake Charles Memorial pays $20.00 a week for one child for
full-time employees and $10.00 a week for one child for part-time employees. Afterschool Care or Academy schools do not
qualify for child care assistance with Lake Charles Memorial Health System. Please contact the Human Resources Department to
find out which licensed facilities are participating in the program and for details on method of payment.
Sick Child Day Care
Sick Child Day Care, located at 2708 2nd Ave., Suite C, provides peace of mind to the working parent knowing that your child
is being taken care of while they are sick allowing you to come to work. Sick Child Day Care is available to all employees,
Monday – Friday 6:00 a.m. - 6:00 p.m. for children ages 6 weeks to 13 years. The cost is $5.00 a day. Full and Part-Time
employees can charge the fee on their badge, if eligible, or pay at time of service. To utilize this service, contact Nurse Staffing
and speak with the House Supervisor at least 2 hours prior to your shift. The Nurse Staffing contact number is 337-494-3215.
Do not leave a message; make sure you speak to the House Supervisor. The House Supervisor will need to know the employee’s
name, department name, child’s name, type of sickness, child’s age and what time you need an attendant to be there.
Paid Time Off (PTO) and Extended Leave Bank (ELB)
It is the policy of Lake Charles Memorial Health System to provide compensated leave time to all eligible employees based on
employment status and length of service. All full-time and part-time employees excluding those classified as temporary, contract
or PRN are eligible for paid leave benefits. Hours begin accruing effective with the date of hire or the effective date of a status
change, but are not eligible to use until the pay period following satisfactory completion of the ninety (90) day introductory period.
This time can be used in increments of two (2) hours or more for planned and unplanned time off in accordance with departmental
policy. The accrual schedule for full-time employee PTO is as follows:
HOURS ACCRUED
PTO HOURS PER YEAR
PER PAY PERIOD
1 to 5
6.46
168 Hours
5 to 15
8.00
208 Hours
15 + years
9.54
248 Hours
*PTO hours will carry over to the next year. The maximum accrual for each level is the equivalent of two years of an annual accrual.
YEARS OF SERVICE
The Extended Leave Bank is available to full-time and part-time employees. ELB hours cannot be utilized until 24 hours of PTO
have been used, unless you are hospitalized or have a procedure requiring moderate (conscious) sedation.
Full-time employees accrue 9 days/72 hours per year or 2.77 hours per pay period with a maximum accrual of 320 hours.
Part-time employees accrue PTO and ELB based on hours paid in the pay period.
18
More Valued Benefits Offered Through Lake Charles Memorial Health System
Bereavement Leave
It is the policy of Lake Charles Memorial Health System to grant up to 24 hours of bereavement leave to eligible full time
employees and 12 hours to eligible part time employees in the event the employee suffers a loss of an immediate family member.
For the purposes of this policy, immediate family members are defined as spouse, mother, father, sister, brother, son, daughter,
mother-in-law, father-in-law and legal guardian. In the event of the loss of a grandparent Lake Charles Memorial will grant up to
16 hours of bereavement leave to eligible full time employees and 8 hours to eligible part time employees. Please refer to the
policy which can be found on the intranet.
Payroll Deduction Charge System
Full-Time and part-time employees of Lake Charles Memorial Health System can use their employee identification badge to
purchase items in the gift shop, pharmacy and cafeteria through payroll deduction. You must sign up for this benefit through
Human Resources and remain an employee “in good standing” as it is defined in the policy in order to use this benefit.
Direct Deposit
This benefit provides a safe, confidential and convenient way for all employees to receive wage and compensation payments
via direct deposit. Employees must complete a Direct Deposit Authorization Form as part of the enrollment process as a new
hire. The form requires the name and address of the Financial Institution; designation as to whether the account is a checking or
savings account; account number, routing/transit number, date and signature of employee. Checking accounts require a voided
check and other accounts require a letter from the financial institution providing the type of account, account # and routing/transit
number. Failure to complete the appropriate Direct Deposit paperwork prior to the first day of work will
result in a delayed start date. Continued failure to do so could result in disciplinary action.
Cellular Phone Plan Discounts
As an employee of Lake Charles Memorial Health System you are eligible to receive discounts through various cellular phone
service providers such as AT&T, Sprint and Verizon. Please contact your Human Resources Department for more information on
how you could start saving today!
Wishing Well Gift Shop Birthday Discount
All employees receive a 25% discount off of any one item in the Wishing Well gift shop to be used any time during the 30 days
prior to or 30 days after your birthday. Happy birthday from Lake Charles Memorial Health System!
Discounted Gym Memberships (contact the wellness department for a complete listing)
Your ID badge must be shown to receive the corporate discount
Gym Discounted price or % off membership fee
LCMH Cardiac Rehab Gym Memorial Main Campus
$5 per month with payroll deduction
Anytime Fitness
Lake Charles 337-478-2727
Moss Bluff 337-855-2777
$30 individual • $50 couple
$30 individual • $50 couple
CrossFit CSE
$90 individual • $50 to add spouse
Curves
$19 sign up fee - with one week free classes.
Contact the LCMH wellness program for discount voucher (494-2992)
Dynamic Dimensions
Moss Bluff 337-855-7708
Sulphur 337-527-5459
$39.00 individual • $54 family
$39.00 individual • $54 family
GiGi’s Fitness Center
$35.16 individual • $59.27 family
LC Fitness
$36.16 Individual • $48 family
Project Fit classes;
$225 boot camps • $25 membership fee with free pass to Saturday
OR 10% off the punch card plans
T’ai Chi Chih Center
$10 off 8-week sessions (classes run in a session of 8-weeks)
The Yoga Center
20% off membership packages or $10
20% off membership packages or $10
19
The following are mandated notices
we
requiredUnder
to distribute
Premiumare
Assistance
Medicaidanually
and the
Children’s Health Insurance Program (CHIP)
Premium Assistance Under Medicaid and the
or your children are eligible for Medicaid or CHIP andChildren’s
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am that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, yo
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but you
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more information,
visitcan
www.healthcare.gov.
won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace.
For more information, visit www.healthcare.gov.
or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find o
ium assistance
is your
available.
If you or
dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if
premium assistance is available.
or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of thes
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these
ams, contact
your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask yo
programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your
if it has a state
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if it has
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are eligiblearefor
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yourmust
employer
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and you
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o enroll inyou
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enrollment”
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days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at
of being www.askebsa.dol.gov
determined eligible
for
premium
assistance.
If
you
have
questions
about
enrolling
in
your
employer
plan,
contact
the
Department
of Lab
or call 1-866-444-EBSA (3272).
.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states
is current as of July 31, 2016. Contact your State for more information on eligibility –
u live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of st
rrent as of July 31, 2016. Contact your State
for more information on eligibility – FLORIDA – Medicaid
ALABAMA – Medicaid
Website: http://myalhipp.com/
Phone:
1-855-692-5447 – Medicaid
ALABAMA
Website: http://myalhipp.com/
ALASKA – Medicaid
The AK Health Insurance Premium Payment Program
Phone: 1-855-692-5447
Website: http://myakhipp.com/
Phone:ALASKA
1-866-251-4861
– Medicaid
Email:Insurance
[email protected]
The AK Health
Premium Payment Program
Medicaid Eligibility:
Website: http://myakhipp.com/
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Phone: 1-866-251-4861
ARKANSAS – Medicaid
Email: [email protected]
Medicaid Eligibility:
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
20
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
FLORIDA – Medicaid
Website: http://flmedicaidtplrecovery.com/hipp/
GEORGIA – Medicaid
Website: 1-877-357-3268
http://dch.georgia.gov/medicaid
Phone:
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
GEORGIA – Medicaid
Website: http://dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
INDIANA – Medicaid
INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.hip.in.gov
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
IOWA – Medicaid
Website: http://www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
NEW HAMPSHIRE – Medicaid
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
To see
nce
ou
ace.
out if
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
MAINE – Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
MINNESOTA – Medicaid
se
our
Website: http://mn.gov/dhs/ma/
Phone: 1-800-657-3739
low
in 60
bor at
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht
m
Phone: 573-751-2005
tates
MISSOURI – Medicaid
MONTANA – Medicaid
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831 2017 employee benefit
NORTH CAROLINA – Medicaid
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/indexes.html
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
3
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIP
P
Phone: 1-800-694-3084
Website: http://www.dhs.pa.gov/hipp
Phone: 1-800-692-7462
Website:
http://dhhs.ne.gov/Children_Family_Services/AccessNe
braska/Pages/accessnebraska_index.aspx
Phone: 1-855-632-7633
Website: http://www.eohhs.ri.gov/
Phone: 401-462-5300
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
NEBRASKA – Medicaid
NEVADA – Medicaid
SOUTH DAKOTA - Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
guide
RHODE ISLAND – Medicaid
SOUTH CAROLINA – Medicaid
WASHINGTON – Medicaid
Website: http://www.hca.wa.gov/free-or-low-costhealth-care/program-administration/premiumpayment-program
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website:
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/
Pages/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
WISCONSIN – Medicaid and CHIP
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.
pdf
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.
cfm
CHIP Website:
4
cfm
CHIP Phone: 1-855-242-8282
e if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact
either:
21
CHIP Website:
cfm
CHIP Phone: 1-855-242-8282
To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
5
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a
valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is
approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a
currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a
collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor,
Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC
20210 or email [email protected] and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 10/31/2016)
MEDICARE PART D
Important Notice from Lake Charles Memorial Health System About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with
Lake Charles Memorial Health System and about your options under Medicare’s prescription drug coverage. This information can help you decide
whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which
drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information
about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1.
Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans
provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2.
Lake Charles Memorial Health System has determined that the prescription drug coverage offered by the Lake Charles Memorial Health
System Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is
therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher
premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
6
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month
Special Enrollment Period (SEP) to join a Medicare drug plan.
What
to Join
Join A
A Medicare
Medicare Drug
Drug Plan?
Plan?
What Happens
Happens to
to Your
Your Coverage
Coverage If
If You
You Decide
Decide to
IfIf you
current Lake
Lake Charles
Charles Memorial
Memorial Health
Health System
System coverage
coverage will
will be
be affected.
affected.See
Seethe
theSummary
SummaryPlan
Plan
you decide
decide to
to join
join aa Medicare
Medicare drug
drug plan,
plan, your
your current
Description
Description for
for additional
additional information.
information.
IfIf you
drop your
your current
current Lake
Lake Charles
Charles Memorial
Memorial Health
Health System
System coverage,
coverage, be
be aware
awarethat
thatyou
youand
andyour
your
you decide
decide to
to join
join aa Medicare
Medicare drug
drug plan
plan and
and drop
dependents
will
be
able
to
get
this
coverage
back.
dependents will be able to get this coverage back.
When
to Join
Join A
A Medicare
Medicare Drug
Drug Plan?
Plan?
When Will
Will You
You Pay
Pay A
A Higher
Higher Premium
Premium (Penalty)
(Penalty) to
You
your current
current coverage
coverage with
with Lake
Lake Charles
Charles Memorial
Memorial Health
Health System
System and
and don’t
don’tjoin
joinaaMedicare
Medicaredrug
drugplan
plan
You should
should also
also know
know that
that ifif you
you drop
drop or
or lose
lose your
within
63
continuous
days
after
your
current
coverage
ends,
you
may
pay
a
higher
premium
(a
penalty)
to
join
a
Medicare
drug
plan
later.
within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
IfIf you
coverage ends,
ends, your
your monthly
monthly premium
premium may
may go
go up
up by
by at
at least
least 1%
1% of
of the
the Medicare
Medicarebase
basebeneficiary
beneficiary
you go
go 63
63 continuous
continuous days
days after
after your
your current
current coverage
premium
did not
not have
have that
that coverage.
coverage. For
For example,
example, ifif you
you go
go nineteen
nineteen months
months without
withoutcreditable
creditablecoverage,
coverage,your
your
premium per
per month
month for
for every
every month
month that
that you
you did
premium
than the
the Medicare
Medicare base
base beneficiary
beneficiary premium.
premium. You
You may
may have
have to
to pay
paythis
thishigher
higherpremium
premium(a
(apenalty)
penalty)
premium may
may consistently
consistently be
be at
at least
least 19%
19% higher
higher than
as
coverage. In
In addition,
addition, you
you may
may have
have to
to wait
wait until
until the
the following
following October
Octoberto
tojoin.
join.
as long
long as
as you
you have
have Medicare
Medicare prescription
prescription drug
drug coverage.
22
For More Information About This Notice Or Your Current Prescription Drug Coverage…
We
are Memorial. Everything your healthcare should be.
Contact
NOTE: You
You will
will also
also get
get itit before
before the
the next
next period
period you
you can
can join
joinaaMedicare
Medicaredrug
drugplan,
plan,and
andififthis
this
Contact the
the person
person listed
listed below
below for
for further
further information.
information. NOTE:
premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your
premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty)
as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
Contact the person listed below for further information. NOTE: You will also get it before the next period you can join a Medicare drug plan, and if this
coverage through Lake Charles Memorial Health System changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the
handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
CMS Form 10182-CC
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
For more information about Medicare prescription drug coverage:
●
Visit www.medicare.gov
●
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their
telephone number) for personalized help.
●
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help,
visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
REMEMBER: KEEP THIS CREDITABLE COVERAGE NOTICE. IF YOU DECIDE TO JOIN ONE OF THE MEDICARE DRUG PLANS, YOU MAY BE REQUIRED TO
PROVIDE A COPY OF THIS NOTICE WHEN YOU JOIN TO SHOW WHETHER OR NOT YOU HAVE MAINTAINED CREDITABLE COVERAGE AND, THEREFORE,
WHETHER OR NOT YOU ARE REQUIRED TO PAY A HIGHER PREMIUM (A PENALTY).
Name of Entity/Sender:
Contact—Person/Office:
Address:
Phone Number:
Lake Charles Memorial Health System
Karen Colston
3050 Aster St.
6050
Lake Charles, LA 70601
337-494-3255
57337-494-3255
When Will You Pay A Higher Premium (Penalty) to Join A Medicare Drug Plan?
Since the coverage under Lake Charles Memorial Health System, is not creditable, depending on how long you go without creditable prescription drug
coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare
drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, your monthly premium may go
up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go
nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium.
You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until
the following October to join.
CMS Form 10182-CC
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
WOMEN’S HEALTH AND CANCER RIGHTS ACT NOTICE
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related
services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications
resulting from a mastectomy, including lymphedema? Call your plan administrator at the number listed on your medical identification
card for more information.
23
Resources
PRODUCT
CARRIER
PHONE NUMBER AND/
OR EMAIL ADDRESS
Human Resources Department
WEBSITE
Hospital website: www.lcmh.com
1-337-494-3255
Benefits Department
Employee Intranet: http://
lcmhweb/sitepages/home.aspx
[email protected]
Meritain Health
Health and Dental Claims:
1-866-760-9569
www.meritain.com
(Group Number: 14938)
RxBenefits
1-800-334-8134
www.rxbenefits.com
Diabetic Program
Managed Care Concepts
1-866-750-2723
www.genesishealthtechnologies.com
In-Network Pharmacy
Medical Plaza Pharmacy
1-337-494-2990
VSP
1-800-877-7195
www.vsp.com
Meritain Health
1-800-566-9305
www.meritain.com
Employer Paid Life Insurance
Voluntary Term Life AD&D
Employer Paid Long Term Disability
Voluntary Short Term Disability
Cigna
1-888-842-4462
www.mycigna.com
FMLA
Cigna
1-888-842-4462
www.mycigna.com
Cigna
1-800-538-3543
www.cignabehavioral.com/CGI
Group Accident Insurance
Group Critical Illness Insurance
Hospital Indemnity Insurance
Unum
1-800-635-5597
www.unum.com
American United Life
Insurance Company
One America Financial
Partner
1-800-249-6269
www.lcmhretirementplan.com
(Group Number: G62261)
Investment Advice
Jeff Wylie
Cambridge Investment
Research
1-985-892-6213
www.fresourcectr.com
Sick Child Day Care
Lake Charles Memorial
Health System
Nurse Staffing
1-337-494-3215
Health/Dental Plan and Claims
Administrator
Pharmacy Benefits Manager
Vision
Flexible Spending Account
Retirement
PO Box 853921
Richardson, TX 75085-3921
Online Benefits Management
SmartBen
Get Healthy, Stay Healthy Wellness
Program
WellSteps
www.smartben.com
337-494-2992 or
337-494-2771
www.wellsteps.com/lcmh
The information in this guide should in no way be construed as a promise or guarantee of employment or benefit coverage. Pricing, underwriting, plan specifics and all other
product features are solely that of the Insurance Company and not National Benefits Group of America. If there is a conflict between the information in this guide and the
actual plan document or policies, the documents or policies will always govern. Complete details about the benefits can be obtained by reviewing current plan descriptions,
contracts, certificates, policies and plan documents available from the Benefits Department.

2017 Employee Benefits Guide - Lake Charles Memorial Hospital

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